Have you entered a plea of guilty, no contest,nolo contendere, or otherwise been
convicted of a criminal act involving controlled substances?

YesNO

Have you entered a plea of guilty, no contest,nolo contendere, adjudication of
guilt (SIS), or otherwise been convicted of a felony or a misdeanor (including
but not limited to such offenses as DUI, battery, theft, writing worthless
checks, suspended license, etc.)?

YesNO

Are you attending school or planning to enroll?

YesNO If Yes list school:

Education/Special Training/Skills/Hobbies:

Is there a specific area or Hospital you would like to work?

Is there any area you prefer not to work?

When are you able to volunteer?

MorningsAfternoonsEveningsWeekends

How many hours a week would you like to volunteer?

How did you learn about our volunteer program?

List previous volunteer experience:

Why do you want to be a volunteer?

Why did you choose CoxHealth?

Person to contact in case of emergency:

Name

Telephone

Relationship

Place of Employment

I understand that effective November 21, 2013, CoxHealth and its Affiliates
will no longer place individuals for volunteer service who use tobacco
products. By submitting this Application for Volunteering, I represent and
agree (1) if placed after November 21, 2013 CoxHealth will not accept me as a
volunteer if I am a tobacco user or test positive for nicotine use, (2)
CoxHealth pre-placement procedures include urine screening for nicotine use,
(3) if an offer of volunteer placement has been extended, CoxHealth will
withdraw the offer if I am in violation of this policy, and (4) if placed in
volunteer service by the CoxHealth after November 21, 2013, I will not during
my volunteering use any tobacco product. I understand that use of a tobacco
product during my volunteer service with the System is grounds for corrective
action which may include immediate termination of volunteer placement.